TRITRIAL: The Impact of Fixed Triple Therapy with Beclometasone/Formoterol/Glycopyrronium on Health Status and Adherence in Chronic Obstructive Pulmonary Disease in an Italian Context of Real Life

Purpose

The TRITRIAL study assessed the effects of beclometasone dipropionate/formoterol fumarate/glycopyrronium (BDP/FF/G) fixed combination in patients with chronic obstructive pulmonary disease (COPD) in a real-world setting, focusing on patient's experience and perspective through the use of patients reported outcomes.

Patients and Methods

TRITRIAL was a multicenter, prospective, observational study conducted on patients with moderate-severe COPD treated with BDP/FF/G fixed therapy for 12 months. The main objective was to evaluate the impact of BDP/FF/G on health status through the COPD Assessment Test (CAT) score. Additional assessments included adherence and satisfaction, measured by the TAI-10/12 questionnaire and a specifically designed eight-item questionnaire, quality of life through the EQ-5D-5L test, sleep quality through the COPD and Asthma Sleep Impact Scale (CASIS), as well as safety and disease-related outcomes.

Results

Data from 655 patients were analyzed in the study. The mean total CAT score significantly improved (from 22.8 at baseline to 18.1 at 6 months and 16.5 at 12 months; p < 0.0001), as well as all the eight CAT sub-items, which decreased on average by 0.5-0.9 points during the study. Adherence and usability of the inhaler also improved during the study, with a decrease in poor compliance (from 30.1% to 18.3%) and an increase in good compliance (from 51.8% to 58.3%) according to the TAI score. Patients also benefited from significantly improved quality of life (EQ Index from 0.70 to 0.80; EQ-5D VAS score from 55.1 to 63.1) and sleep quality (CASIS score from 41.1 to 31.8). Finally, patients reported a significant reduction in exacerbation during the study.

Conclusion

TRITRIAL showed that the BDP/FF/G fixed combination is effective and safe in patients with moderate-severe COPD and poorly controlled disease, improving patients' HRQoL, sleep quality, adherence and inhaler usability and reducing COPD symptoms and the risk of exacerbation in a real-life setting.

BDP/FF NEXThaler to Improve Asthma Control Status in the Real World: The NEWTON Study

In this article, we discuss the importance of real-world data in the treatment of patients with asthma and specifically the role of maintenance and reliever therapy (MART) with beclometasone dipropionate (BDP)/formoterol fumarate dihydrate (FF) delivered through a dry-powder inhaler (DPI) that contains an extrafine formulation. We also present the design of the NEWTON study. This multinational, multicenter, prospective, observational study will evaluate the real-world use of extrafine BDP/FF via a DPI as maintenance therapy and MART in patients with moderate to severe asthma. The study's primary outcome will be the proportion of patients improving their asthma control. Digitally collected patient-reported outcomes, such as the 5-item Asthma Control Questionnaire, the EuroQol 5-dimension 5-level, and the Test of the Adherence to Inhalers, will be used to assess the patient's asthma control, quality of life, and treatment adherence. Moreover, a new patient-reported outcome, the "Speed of change in health feeling" questionnaire, will be validated in a subgroup of patients. Overall, the results of this study will provide a real-life assessment of patients who perceived clinical benefits in a large cohort of asthmatics in Europe treated as per current clinical practice.

No-shaking and shake-fire delays affect respirable dose for suspension but not solution pMDIs

It has long been accepted that suspension pressurized metered-dose inhalers (pMDIs) must be shaken if a correct dose is to be delivered, if not, it will usually be higher than the label claim. The purpose of this work was to investigate the influence of the device being unshaken, shaken and after a period of delay in pMDI actuation on the Fine Particle Mass (<5 µm), Extra Fine Particle Mass (<2 µm) and MMAD. Solution and suspension commercial pMDIs containing one, two or three components were used in the study. Most of the suspension pMDIs produced variable amounts of respirable size drug following the shake-fire delays tested in terms of the label claim dose. The effect was even more critical if the inhaler was not shaken and the FPM was found to be between -82 % for Symbicort and 363 % for Ventolin compared with the control values. In the case of MMAD measurements, Seretide and Serzyl inhalers showed the largest change from around 3 µm to 4.2-5.1 µm when not shaken. Conversely, the FPM and MMAD for the solution aerosols remained unchanged whether or not they were shaken or when a progressive increase in the delay in actuation after shaking was employed.

Impulse Oscillometry, Small Airways Disease, and Extra-Fine Formulations in Asthma and Chronic Obstructive Pulmonary Disease: Windows for New Opportunities

In recent years, the perspective of management of respiratory disease has been gradually changing in light of the increasing evidence of small airways as the major site of airflow obstruction contributing to the development of both COPD and asthma already in early stages of disease. First and foremost, the evidence is redefining disease severity, identifying small airways disease phenotypes and early signs of disease, and revising prevalence and overall epidemiological data as well. Much effort has been put toward the instrumental assessment of small airways’ involvement and early detection. Several clinical trials have evaluated the advantage of extra-fine formulations which can best target the small airways in uncontrolled asthma and severe COPD. Here, we briefly present a practical overview of the role of the small airways in disease, the most appropriate diagnostic methods for quantifying their impairment, and provide some insight into the costs of respiratory management in Italy, especially in sub-optimally controlled disease.

Decreased humoral immune response in the bronchi of rapid decliners with chronic obstructive pulmonary disease

Background

Identification of COPD patients with a rapid decline in FEV1 is of particular interest for prognostic and therapeutic reasons.

Objective

To determine the expression of markers of inflammation in COPD patients with rapid functional decline in comparison to slow or no decliners.

Methods

In COPD patients monitored for at least 3 years (mean ± SD: 5.8 ± 3 years) for lung functional decline, the expression and localization of inflammatory markers was measured in bronchial biopsies of patients with no lung functional decline (FEV1% + 30 ± 43 ml/year, n = 21), slow (FEV1% ml/year, − 40 ± 19, n = 14) and rapid decline (FEV1% ml/year, − 112 ± 53, n = 15) using immunohistochemistry. ELISA test was used for polymeric immunoglobulin receptor (pIgR) quantitation “in vitro”.

Results

The expression of secretory IgA was significantly reduced in bronchial epithelium (p = 0.011) and plasma cell numbers was significantly reduced in the bronchial lamina propria (p = 0.017) of rapid decliners compared to no decliners. Bronchial inflammatory cell infiltration, CD4, CD8, CD68, CD20, NK, neutrophils, eosinophils, mast cells, pIgR, was not changed in epithelium and lamina propria of rapid decliners compared to other groups. Plasma cells/mm² correlated positively with scored total IgA in lamina propria of all patients. “In vitro” stimulation of 16HBE cells with LPS (10 μg/ml) and IL-8 (10 ng/ml) induced a significant increase while H₂O₂ (100 μM) significantly decreased pIgR epithelial expression.

Conclusion

These data show an impaired humoral immune response in rapid decliners with COPD, marked by reduced epithelial secretory IgA and plasma cell numbers in the bronchial lamina propria. These findings may help in the prognostic stratification and treatment of COPD.

The 5T approach in asthma: Triple Therapy Targeting Treatable Traits

Using a therapeutic strategy that is free from traditional diagnostic labels and based on the identification of "treatable traits" (TTs), which are influential in clinical presentations in each patient, might overcome the difficulties in identifying and validating asthma phenotypes and endotypes. Growing evidence is documenting the importance of using the triple therapy with ICS, LABA, and LAMAs in a single inhaler (SITT) in cases of asthma not controlled by ICS/LABA and in the prevention of exacerbations. The identification of TTs may overcome the possibility of using SITT without considering the specific needs of the patient. In effect, it allows a treatment strategy that is closer to the precision strategy now widely advocated for the management of patients with asthma. There are different TTs in asthma that may benefit from treatment with SITT, regardless of guideline recommendations. The airflow limitation and small airway dysfunction are key TTs that are present in different phenotypes/endotypes, do not depend on the degree of T2 inflammation, and respond better than other treatments to SITT. We suggest that the 5T (Triple Therapy Targeting Treatable Traits) approach should be applied to the full spectrum of asthma, not just severe asthma, and, consequently, SITT should begin earlier than currently recommended.

Why small particle fixed dose triple therapy? An excursus from COPD pathology to pharmacological treatment evolution

Although bronchodilators are the cornerstone in chronic obstructive pulmonary disease (COPD) therapy, the treatment with a single-agent bronchodilator may not provide adequate symptoms control in COPD. The combination of drugs with different mechanisms of action may be more effective in inducing bronchodilation and preventing exacerbations, with a lower risk of side-effects in comparison with the increase of the dose of a single molecule. Several studies comparing the triple therapy with the association of long-acting ß2 agonist (LABA)/inhaled corticosteroid (ICS) or long-acting muscarinic antagonist (LAMA)/LABA reported improvement of lung function and quality of life. A significant reduction in moderate/severe exacerbations has been observed with a fixed triple combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium (G) in a single inhaler. The TRILOGY, TRINITY and TRIBUTE studies have provided confirming evidence for a clinical benefit of triple therapy over ICS/LABA combination treatment, LAMA monotherapy and LABA/LAMA combination, with prevention of exacerbations being a key finding. A pooled post hoc analysis of the published clinical studies involving BDP/FF/G fixed combination demonstrated a reduction in fatal events in patients treated with ICS-containing medications, with a trend of statistical significance [hazard ratio = 0.72, 95% confidence interval (CI) 0.50-1.02, p = 0.066], that becomes significant if we consider reduction in fatal events for non-respiratory reasons (hazard ratio = 0.65, 95% CI 0.43-0.97, p = 0.037). In conclusion, a fixed combination of more drugs in a single inhaler can improve long-term adherence to the therapy, reducing the risk of exacerbations and hospital resources utilization. The twice a day administration may provide a better coverage of night, particularly in COPD patients who are highly symptomatic. The inhaled extrafine formulation that allows drug deposition in both large and small - peripheral - airways, is the value added.

Narrative Analysis of the Impact of COVID-19 on Patients with Chronic Obstructive Pulmonary Disease, Their Caregivers, and Healthcare Professionals in Italy

Purpose

The COVID-19 pandemic has disrupted many lives, including those of people suffering from chronic obstructive pulmonary disease (COPD) and their caregivers. The main aim of this study was to use narrative medicine, a validated approach promoting quality of care to explore how the COVID-19 pandemic impacted the quality of care, quality of life, psychological factors and social factors of people affected by COPD and their caregivers and healthcare professionals (HCPs). A secondary aim was to explore the role of telemedicine in combating isolation and providing access to care.

Methods

A cross-sectional observational narrative medicine study was conducted between July and November 2020 across Italy. An online semi-structured questionnaire with a narrative plot was completed by 146 participants (79 COPD patients, 24 caregivers, and 43 HCPs). Narrations were analyzed with descriptive statistics and evaluated using NVivo 11 software to break down the text and identify recurring themes and major semantic clusters.

Results

During the first lockdown, 58.22% of responses from COPD patients indicated terror, fear and/or apprehension; at reopening, this figure was 35.44%. Among caregivers, these figures were 100% at first lockdown and 45.83% at reopening. The metaphors most commonly used by patients to describe COPD and COVID-19 were monster and murderer, respectively. Patients described their homes more often as clean and lonely than as offering no shelter. The narratives of 42 COPD patients (45.2%) described coping. Only 12.6% of COPD patients reported regular access to medical visits during lockdown, while 59.1% of general practitioners and pulmonologists reported using telemedicine, which was perceived as satisfactory by both patients and caregivers.

Conclusion

It is relevant to aim for a multidisciplinary and multilevel system of care that empowers telemedicine and integrates specific psychological support programs for COPD patients and their caregivers.

Beclomethasone/Formoterol in Extra-Fine Formulation Improves Small Airway Dysfunction in COPD Patients

Introduction

In patients with chronic obstructive pulmonary disease (COPD), small airway dysfunction (SAD) is a key element and a functional consequence of the pathology. The exact role of SAD as a specific ‘pharmacological target’ represents an important research topic. Our objective was to ascertain whether an extra-fine formulation of beclomethasone dipropionate/formoterol fumarate (BDP/FF) NEXThaler^® 100/6 μg b.i.d. could improve SAD and, consequently, the quality of life of COPD patients.

Methods

We enrolled COPD patients with severe airflow obstruction and at least one moderate exacerbation in the previous year, having started treatment with BDP/FF NEXThaler^® for no more than 1 week. Patients underwent three visits: at the start of the treatment (V1), 6 weeks (V2), and 12 weeks later (V3). At each visit, we evaluated the fall in resistance from 5 to 20 Hz (R5–R20) and residual volume/total lung capacity (RV/TLC) ratio by impulse oscillometry, spirometry, and plethysmography. The COPD Assessment Test (CAT) and the modified Medical Research Council (mMRC) questionnaire were also administered to assess the disease’s impact on quality of life.

Results

We enrolled 43 COPD patients (mean age 69 years, FEV₁ 43%). R5–R20 significantly changed from baseline [0.23 ± 0.09 kPa/(l/s)] to V2 [0.16 ± 0.09 kPa/(l/s)] and V3 [0.16 ± 0.08 kPa/(l/s)] (p < 0.05). Clinical status was also significantly improved compared to baseline; in fact, CAT score changed from an average baseline value of 13–6 and 4 (V2 and V3, respectively) (p < 0.05). A correlation was found between CAT percentage change values and the corresponding ones of R5–R20 (r = − 0.329, p = 0.045) and RV/TLC (r = 0.354, p = 0.029).

Conclusions

In COPD patients, treatment with BDP/FF extra-fine formulation improved functional parameters related to small airway disease as well as the disease impact on health status.

Trial Registration

ClinicalTrials.gov identifier, NCT04421742.

The Impact of Fixed Triple Therapy with Beclometasone/Formoterol/Glycopyrronium on Health Status and Adherence in Chronic Obstructive Pulmonary Disease (COPD) in an Italian Context of Real Life: The TRITRIAL Study Protocol

Background

The fixed triple combination Beclometasone dipropionate/Formoterol fumarate/Glycopyrronium (BDP/FF/G, Trimbow^®), an extrafine formulation in a unique pressurized metered dose inhaler, is indicated for the maintenance treatment in adult patients with moderate to severe COPD, not adequately treated by ICS/LABA or LABA/LAMA. Besides the evidence from three randomized controlled trials, the impact of fixed triple therapy has not been extensively evaluated in a real-world population of COPD patients. TRITRIAL (TRIple Therapy in Real life: Impact on Adherence and HeaLth status) is a non-interventional study to assess the effect of BDP/FF/G in a real world setting in Italy.

Design

TRITRIAL is a 12-month, multicenter, cohort, prospective, longitudinal observational study. Two follow-up visits will be performed at 6 and 12 months, respectively. The study includes the collection of anamnestic clinical and functional data before the start of BDP/FF/G. The study is built for digital conduction, from signature of the informed consent on a dedicated web platform, to the collection of questionnaires and clinical data on the eCRF.

Population

A total of 800 patients with COPD ranging from Global Initiative for Obstructive Lung Disease (GOLD) stages 2 to 4, receiving therapy with BDP/FF/G according to the Summary of Product Characteristics and local clinical practice, will be recruited. All concomitant therapies will be permitted for the duration of the study.

Evaluations

The primary endpoint is the change of CAT score at 12 months versus baseline. Secondary endpoints are adherence, health-related quality of life, sleep quality, disease-related outcomes (lung function and COPD exacerbations), device usability, economic resources consumption, and safety.

Conclusion

TRITRIAL study is expected to give relevant information about effectiveness of BDP/FF/G fixed triple therapy in a real-life setting of patients with COPD, where adherence, usability of inhalers and patient’s preference of the device are crucial factors for the success of the therapy.

Adherence to COPD free triple inhaled therapy in the real world: a primary care based study

INTRODUCTION

The development of new pharmacological treatments for chronic obstructive pulmonary disease (COPD) has improved health-related quality of life of patients. However, suboptimal adherence may limit its potential.

OBJECTIVE

The aim of the present study was to assess the adherence to free triple inhaled therapy and to investigate poor adherence determinants among primary care patients.

METHODS

Data were derived from a primary care database in Italy. Patients aged 40+ affected by COPD and prescribed with inhaled corticosteroids, long-acting beta agonists and long-acting muscarinic antagonists (N = 3177) were enrolled. Low adherence was defined as a proportion of days covered (PDC) by medications prescription lower than 80%. Predictors of low adherence were tested using logistic regression models.

RESULTS AND CONCLUSIONS

The 85% of enrolled patients showed poor adherence to free triple inhaled therapy. Comorbidities, such as heart failure (OR 1.78, 95%CI 1.19-2.75), depression (OR 1.41, 95%CI 1.06-1.88) and peripheral vascular disease (OR 1.32, 95%CI 1.01-1.74) were associated with poor adherence. Former (OR 0.52, 95%CI 0.34-0.78) or current smokers (OR 0.61, 95%CI 0.41-0.93) and patients with more severe airways obstruction or history of severe exacerbations (OR 0.64, 95%CI 0.52-0.79) were less likely to exhibit poor adherence. Real-world adherence to triple inhaled therapy with different inhalers is generally low. Higher GOLD airways obstruction stage and current or former smoking status are associated with increased adherence to treatment. Reduced perceived benefit on symptoms control is probably linked to poorer adherence to free triple therapy.

Consequences of not-shaking and shake-fire delays on the emitted dose of some commercial solution and suspension pressurized metered dose inhalers

BACKGROUND

Pressurized metered-dose inhalers (pMDIs) include hydrofluoroalkane (HFA) propellant to generate a drug aerosol upon actuation and drugs can be formulated as solution or suspension. Suspended particles can cream or sediment depending on density differences between drug and propellant and shaking the pMDI is an essential step to ensure a uniform drug dose release.

RESEARCH DESIGN AND METHODS

The effect of the delay (0, 10, 30, 60 seconds) in pMDI actuation after shaking and the effect of no-shaking during the canister life on the emitted dose (ED) for commercial solution and suspension pMDIs was investigated.

RESULTS

The ED for solutions was unaffected by no-shaking or by the progressive increasing delay in actuation after shaking (between 77% and 97%). For all the suspension products, shaking was demonstrated to be critical to assure the close to nominal drug delivery. In detail, the actuation delay after shaking led to an increase up to 380% or a drop to 32% of ED in relation to the label claim with high variability.

CONCLUSION

The drug delivered can vary widely for no-shaking and over different shake-fire delays with suspension pMDIs while solution formulations appear to remain stable.

Day and Night Control of COPD and Role of Pharmacotherapy: A Review

The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients’ adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient’s profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic “24-hour control of COPD and role of pharmacotherapy”, held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.

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Enlightening chronic obstructive pulmonary disease through patients' and caregivers' narratives

Purpose

The primary aim of this research was to raise awareness for COPD through real narratives of patients, caregivers, and pulmonologists. The second objective includes providing clinicians new means of caring for and treating patients with COPD.

Methods

Using narrative medicine, testimonies from patients, their caregivers, and clinicians were collected through an online questionnaire enriched by a narrative plot. Narrations were analyzed throughout descriptive statistics and an elaboration of recurring words and expressions.

Results

Throughout the project, 350 narratives were collected from 235 patients, 55 caregivers, and 60 physicians. Though a generally neutral reaction had been observed upon diagnosis, COPD had been found to have a high impact on the patients’ and caregivers’ lives. Metaphors utilized by patients and caregivers were suggestive of fear and panic unlike those utilized by clinicians who usually had a more technical approach. Smoking was a significant concern for not only patients and caregivers but also clinicians.

Conclusion

Physicians are therefore challenged to find new ways of communicating COPD to raise awareness on this pathology and encourage corrective habits. An important social objective should be the implementation of a health system that is able to optimize patients’ and caregivers’ lives.

Sleeve Lobectomy Versus Standard Lobectomy for Lung Cancer: Functional and Oncologic Evaluation

BACKGROUND

The purpose of this study was to compare functional and oncologic outcome of sleeve lobectomy (SL) with that of standard lobectomy (STL) in patients with non-small cell lung cancer.

METHODS

Between January 2009 and April 2013, 44 consecutive patients undergoing upper SL (29 right side, 15 left side) were prospectively enrolled to be compared with 44 patients with the same side distribution who were randomly selected from patients undergoing upper STL during the study period. Functional and oncologic results of the two groups were compared.

RESULTS

Pathologic tumor stage ranged between I and IIIa with similar patient distribution between the two groups. Postoperative complication rates were 20.5% in the SL group and 16% in the STL group. There was no postoperative mortality in either group. Mean postoperative decrease in forced expiratory volume in 1 second at 3 months postoperatively was 17.5% ± 6.2% in the SL group and 19% ± 14.8% in the STL group (p = 0.52). There also was no significant difference (p = 0.15) in mean postoperative decrease in 6-minute walk test (64.3 ± 2.5 m versus 69.1 ± 21.4 m) between the two groups. Evaluation of postoperative changes in quality of life at 3 and 6 months based on a standardized questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire) did not show significant differences between the SL group and the STL group (p > 0.05) in terms of global health status, physical functioning, and fatigue. Actuarial survival rates at 3 and 5 years, respectively, were 85.3% and 60.1% in the SL group and 88.7% and 58.2% in the STL group, without significant difference (p = 0.68).

CONCLUSIONS

Functional and oncologic results of SL are comparable to those of STL in patients with non-small cell lung cancer.

Lung cancer and concurrent or sequential lymphoma: Two case reports with hypersensitivity to bevacizumab and a review of the literature

Non-small cell lung cancer (NSCLC) accounts for ~80% of all cases of lung cancer, and is the leading cause of cancer-related mortality worldwide. The majority of NSCLC cases of are diagnosed at an advanced stage. The outcome of patients with advanced NSCLC is poor with a median survival time of ~12 months in European and American populations. Lymphoproliferative disorders (LPDs) represent a heterogeneous group of expanding lymphoid cells, which occurs as a result of immune dysfunction. LPDs are often associated with primary solid cancers. We report two cases of LPD diagnosed concurrently and successively to NSCLC. The first case presents a 65-year-old female patient with advanced IV stage lung cancer, according to the International Association for the Study of Lung Cancer TNM staging system. The patient developed a concurrent lymphoma and was treated with first-line therapy including six cycles of gemcitabine and cisplatin, however, the patient experienced an adverse drug reaction to bevacizumab, which was administered after gemcitabine and prior to cisplatin. The second case presented a 74-year-old male patient diagnosed with large B cell lymphoma. The patient acheived remission of the illness, however, after one year the patient was diagnosed with squamous cell lung cancer. After three years, the patient underwent surgery, however disease recurrence was identified. Subsequently, the patient was treated with sterotactic radiotherapy and oral chemotherapy. A review of the associated literature was also conducted.

Successful multimodal treatment of a breast cancer patient with a recurrence invading the chest wall

We describe successful operative management of a solitary breast cancer metastasis in the chest wall after complete response with concomitant non-pegylated liposomal doxorubicin (NPLD) and docetaxel followed by sternal rib resection with prosthetic reconstruction. We report a case of a 41-year-old woman who had a breast cancer recurrence infiltrating neighboring osteo-cartilage of the left sternal body, the cartilaginous portion of the third and fourth ipsilateral ribs and was inseparable from the rear side pectoral reaching deep into contiguity with the pericardium. After 6 cycles of chemotherapy with NPLD plus docetaxel, sternal rib resection with prosthetic reconstruction was performed. Histological examination did not show any evidence of residual tumor. At 9 months of follow-up, the patient appears free of disease. Our case demonstrates that a multimodal approach in patients with chest wall recurrence of breast cancer without distant metastasis, may be safe and effective for maintaining a good quality of life.

[Malignant pleural effusion]

Malignant pleural effusion is a frequent condition with important prognostic repercussions on duration and quality of life. The neoplasms that more frequently determine pleural effusion are lung and breast cancer and pleural mesothelioma. Lymphomas, tumours of the genitourinary tract and gastrointestinal tract as a group account for a further 25%. Surgical treatment has palliative purposes and finalized to reduction symptoms and to improve quality of life. More frequent clinical presentation is a massive pleural efusion associated to dyspnoea and cough. Pleural aspiration is the first choice treatment but the recurrence rate equals to 100% within 1 month. Repeated pleural aspirations are indicated in those patients that have lower expectation of life. The recurrence risk can be reduced with chemical pleurodesis that allows the adhesion between pleural surfaces. Pleurodesis can be realized by the instillation of several substances by the tube of drainage (slurry) or during thoracoscopy (poudrage). Video Assisted Thoracoscopy (VATS) is a safe and well tolerated technique, a complication rate is lower than 0.5%, VATS can be used to obtain diagnosis and to treat patients with malignant pleural effusion and better expectation of life.

Post-operative respiratory rehabilitation after lung resection for non-small cell lung cancer

BACKGROUND

To investigate the efficacy of an inpatient Pulmonary Rehabilitation program (i-PR) after lung resection (LR) for Non-Small Cell Lung Cancer (NSCLC).

PATIENTS AND METHODS

From January 2001 to December 2004, 211 out of 618 patients who underwent LR were considered eligible for i-PR. Twenty-five patients accepted the i-PR and were included in the case group. The remaining 186 who refused i-PR were taken as controls.

RESULTS

The two study groups were comparable for demographic and surgical characteristics, as well as for the peri-operative morbidity (4% in the controls and 3% among patients undergoing i-PR). Most functional parameters among treated patients were improved when baseline versus 1-month figures were compared, despite the strong correction for multiple comparison limited statistical significance to Borg scale dyspnoea on exertion - median - (2 versus 0; p<0.01); pH (7.45 versus 7.42; p<0.05); timed walk-6MWD (297.8m versus 393.4m; p<0.01) and Hb saturation during 6MWD (95.4% versus 93.9%; p<0.05). On the contrary, global function in the group of controls was homogeneously decreased (FEV(1) and PEF p<0.01) after operation. The comparison of treated and untreated patients 1 month after the operation did not show any significant difference in terms of FEV(1), FVC, PEF, distance, Hb saturation, and KCO that instead were homogeneously and significantly worse at baseline (before the surgical operation) in the case group.

CONCLUSIONS

Respiratory Function and exercise capacity significantly improve following a post-operative 4-week i-PR in lung resected patients. i-PR could be regarded as a component of the management of patients who have undergone LR for cancer.

Multimodality treatment of unresectable stage III non–small cell lung cancer: Interim analysis of a phase II trial with preoperative gemcitabine and concurrent radiotherapy

OBJECTIVE

We report the preliminary results of a phase II trial undertaken to determine the feasibility and efficacy of gemcitabine and concurrent radiotherapy in patients with inoperable stage III non-small cell lung cancer.

METHODS

Between February 2001 and June 2003, a total of 46 patients (37 male and 9 female, median age 64 years) with clinical stage III non-small cell lung cancer (41 cIIIA and 5 cIIIB) were enrolled in a combined chemoradiation protocol with gemcitabine as the chemotherapeutic agent. Gemcitabine (350 mg/m2) was administered weekly for 5 consecutive weeks as a 30-minute intravenous infusion before radiotherapy (total dose 50.4 Gy, 1.8 Gy/d). Toxicity was routinely assessed. Those patients with disease judged to be resectable at restaging underwent surgery.

RESULTS

Toxicity was moderate, with the exception of 1 grade 3 thrombocytopenia. All but 5 patients were available for restaging. No complete responses were observed. Thirty-four patients (82.9%) had partial responses, 5 (12.2%) had stable disease, and 2 (4.9%) had progressive disease. Twenty-nine of 46 patients (63%, 27 cIIIA and 2 cIIIB) underwent surgery. Radical resection was possible in all cases. Surgery included 17 lobectomies, 4 bilobectomies, and 8 pneumonectomies. There were no deaths. Morbidity was 13.8% (4/29). Pathologic downstaging to stage 0 or I was observed in 18 patients (39%, 18/46). After a median follow-up of 13 months (range 2-28 months), 24 of the patients who had undergone operation (86.2%) were alive, with a median disease-free survival of 16 months. Overall 2-year survival was 66.1%, with a significant difference between resected and unresected disease (82% vs 36%, P = .0002).

CONCLUSION

The results of this induction trial confirm the feasibility and the efficacy of gemcitabine with concurrent radiotherapy.

Neoadjuvant therapy for esophageal cancer: surgical considerations

Esophageal carcinoma is often diagnosed at an advanced, non resectable stage. Only early stages show a better prognosis. Surgical treatment represents the gold standard. The various surgical techniques do not seem to affect survival. Based on the severity of esophageal cancer and on poor outcome achievable with surgery alone, multimodality treatments are the most suitable. The possible negative impact on the complication rate after neoadjuvant therapy is still debated. Most randomized trials have not demonstrated as yet an improvement in prognosis in patients undergoing a three-modality treatment. However, patients with complete pathologic response after surgical resection were shown to have a better prognosis. In conclusion, additional randomized trials are required, aimed at evaluating all technical and therapeutic variables which affect prognosis.

Transhiatal esophagectomy (THE)

In Transhiatal Esophagectomy(THE) two approaches can be used by the surgeon: abdominal and cervical, without thoracotomy. A pioneer of this technique was Orringer, with the largest experience world-wide (1085 patients). THE is associated with a lower morbidity compared with the transthoracic approach, but much controversy exists on whether THE is a suitable operation for cancer, because it is not combined with en-bloc lymphadenectomy. However, overall, there are no statistical differences between the two. Frequently esophageal carcinoma is a systemic disease and thus, the biological behavior and the stage of tumor rather than the technique, play a major role.

Surgical treatment of non-small cell lung cancer: mediastinal lymph node dissection

The effectiveness of lymph node dissection in the treatment of non-small cell lung cancer is evaluated. The extent of lymphadenectomy in the treatment of NSCLC is still controversial. Although some centers perform only mediastinal lymph node sampling with resection of suspicious lymph nodes, others recommend radical, systematic mediastinal lymph node dissection to improve survival and achieve a better staging. Reports of the literature on the subject are reviewed and the results achieved with the various procedures are analyzed. A personal technique to perform mediastinal lymph node dissection is described.

Tnm independent prognostic factors in lung cancer

Large studies have demonstrated that TNM staging system is the most consistent prognostic factor in patients with non small cell lung carcinoma. However, because patients within the same stage may have very different survival, better prognostic information is needed. The recent progress in molecular biology has allowed the analysis of proteins and genes involved in cancer development. To date, more than 150 different prognostic factors affecting survival in patients with lung cancer have been discovered and extensively studied. Despite the encouraging prognostic results in angiogenesis markers, there is not yet a molecular marker validated in large prospective trials that has major independent predictive prognostic value.

[Predisposing factors for development of cardial adenocarcinoma]

After a careful revision of the various papers and on the basis of their personal experience, the persons responsible for this project analyse the factors that, today, influence the development of an adenocarcinoma in the region of the gastro-esophageal junction. They also study therapeutic strategies on the basis of new findings in anatomic-physiological matters of this region. From this analysis, specialists notice an increase in adenocarcinomas which affect the gastric region of the cardia, in comparison with carcinomas which affects the gastric region in toto. By considering Barrett, Hayward, Riedel and Ruol's studies, they maintain that the fundamental factor which causes the development of cardial adenocarcinoma is the gastroesophageal reflux. This reflux acts as a chronic irritative stimulus on the esophageal wall and therefore it provokes an increase in mucous secretion and the formation of metaplasia. This metaplasia is initially mucosecreting, acid-secreting and in the end it becomes intestinal. This also leads to the appearance of absorbent calciform cells; the absorption of toxic or mutagenic substance for the cell itself, will be the next step for the development of an adenocarcinoma. Nowadays the therapy of intestinal metaplasia provides for different therapeutic levels: from the endoscopic monitoring (which is used for the most serious cases of dysplasia), to the PPI medical treatment(today in disuse), to the surgical laparoscopic treatment with non-refluxing plasty (Nissen, Toupet). This last treatment is today associated with endoscopic esophageal mucosectomy in order to achieve a better effectiveness. This happens through the use of various methodologies, for example the multipolar electrocoagulation.

[Lung surgery in the elderly]

Lung surgery in the elderly, once considered a major risk, to be avoided if possible has become more popular in recent years as a result of many factors. First: lung cancer incidence has increased significantly in every age group but mostly in the elderly. Second: diagnosis at an early stage of the disease is higher in patients over 70 due to more frequent medical control in old subjects. Third: we now have more and more humans over 80 and a life expectancy increasing over the years. Fourth: preoperative, operative and postoperative medical supports are now safer and more reliable than previously. Operability criteria in the elderly are substantially the same as in younger group of patients for lung cancer. There are no reasons to refuse surgery in a subject over 80 because he is old. Lobectomy is the procedure of choice for lung cancer even in the elderly. Pneumonectomy must be avoided preferring a less radical procedure (wedge resection) so avoiding the risk of a postoperative respiratory failure that is often fatal for a patient with in border line functional respiratory tests, as often happens in the elderly. Thoracoscopic atypical resections must be considered in patients when a wedge resection is indicated preoperatively and almost always metastatic pulmonary lesion.

[Duodeno-gastric reflux in gallbladder stones and after laparotomic cholecystectomy]

BACKGROUND

Duodeno gastric reflux (DGR) is still a not well-defined condition, even though it has been the subject of different studies for many years.

METHODS

The authors examine its relation with gallstones before and after the surgical removal of the gallbladder. After examining various study techniques, they present their experience of DRG. In this work the methodology used in a group of 40 patients suffering from gallstones and operated by laparotomic cholecystectomy is presented. All patients have been subjected to a clinical questionnaire in order to evaluate their symptoms, before and after cholecystectomy, and at the same time they have been subjected to an endoscopic exam. It s not easy to comment the RESULTS.

RESULTS

Actually, of 32 patients (80%) showing DGR symptoms before surgical treatment, 20 showed their persistence, worsening, or the appearance of new symptoms after cholecystectomy, while 12 were completely asymptomatic. Of 8 patients with no symptoms before cholecystectomy, 3 developed a typical DGR symptomatology while 5 were asymptomatic.

CONCLUSIONS

So 57% of patients were DGR symptomatic after surgical treatment. The compromised function of cholecystitis with calculi, antrum-pyloric-duodenal motility, continuous bile flux in the duodenum, surgical trauma all interact in determining DGR.

[Gastroduodenal reflux after laparotomic or laparoscopic cholecystectomy]

BACKGROUND

The authors analyse gastroduodenal reflux (GDR) in the light of the progress made over the past ten years. The good results achieved using mini-invasive techniques in cholecystectomy prompted the authors to compare laparotomic and laparoscopic cholecystectomy in order to evaluate the influence of both techniques in determining GDR and clinical symptoms.

METHODS

Symptoms were evaluated before and after surgery in 30 patients operated using a laparotomic technique and in 30 patients operated using a laparoscopic technique. Two groups of 10 patients, operated respectively using laparotomic and laparoscopic techniques, were studied both clinically and endoscopically before and after surgery.

RESULTS

The analysis of the results shows a lower incidence of GDR and typical symptoms of GDR in patients undergoing laparoscopic surgery. The rationale underlying the lower incidence of GDR and its symptoms in these patients compared to the more conventional group is not completely clear.

CONCLUSIONS

These results may be influenced by reduced surgical trauma and the careful selection of case or the laparoscopic technique, hence the exclusion of cases complicated by severe cholecystitis.

[Current diagnosis of gastroesophageal reflux disease: learning experience]

The authors report their study on gastro-esophageal reflux disease, a pathology that has become increasingly common over the past years reflecting both a real increase and the use of new and more sophisticated and reliable diagnostic methods and tests. It can be included in the group of pathologies absorbing the largest proportion of financial resources, even exceeding biliary lithiasic disease according to American studies. The authors start by analysing the symptoms of gastroesophageal reflux disease, drawing a distinction between typical (heartburn, epigastric pain and postprandial regurgitation) and atypical symptoms (laryngotracheal symptoms, bronchopulmonary symptoms and esophageal motor incoordination). They outline the diagnostic iter and tests most widely used today to achieve a correct diagnosis. Lastly, they report their experience of 160 patients attending their esophageal diagnostic unit since January 1999 who underwent a number of different instrumental tests, the results of which are compared. Three different aspects are compared: the presence of symptoms, 24-hour pH-metry and endoscopic tests. All these are necessary for a correct diagnosis of gastroesophageal reflux disease and to evaluate the possibility and efficacy of surgery. They emphasise the diagnostic importance of 24-hour pH-measurement as the only test that can directly reveal gastroesophageal reflux. Positive pH results represent a discriminating element in deciding whether the patient should undergo surgery.

[Secondary costal myxoid chondrosarcoma. Presentation of a clinical case]

A type of malignant neoplasm of not frequent observation is reported and the difficulties concerning the distinction from the benign counterpart are underlined, for which a detailed instrumental study is made necessary, integrated with pre and, above all, postoperative histologic analysis. A white male patient of 83, affected by plurirecidivant chondromyxoma of the rib, was admitted for local recurrence. The lesion objectively appeared not dissimilar from the preceding ones, as an ovalar mass fixed on the underlying plains. Radiologic and ultrasonographic examinations seemed to confirm the admission diagnosis; at the end the patient underwent a new intervention. Histologic examination of the lesion yielded a diagnosis of chondromyxosarcoma. The clinical case is made even more interesting by the finding, through the TC technique, preoperatively performed, of a metastatic repetition on the opposite side. The authors examine the problem of the early recognition of a malignant neoplasm developing, in a patient with a clinical history of recidival chondromyxoma. Physical examination and laboratory analysis are not useful in the assessment of the occurring transformation. At molecular level chondromyxosarcoma is characterized by several genomic rearrangements and mutations. Though primitive chondromyxosarcoma often involves the ribs, chondromyxoma's transformation into its malignant counterpart is not a common event. The development of distant metastasis characterizes long term cases. Given the lack of encouraging results about chemo and radio-therapy efficacy in influencing the natural course of the disease, a systematic approach will be made necessary in patient management.

[Ileal occlusion caused by enterolith migrated from Meckel's diverticulum]

The authors present a case report of an intestinal obstruction due to a relatively big coprolite migrated from a large Meckel's diverticulum to the distal Ileum. The patients apparently healthy and a vegetarian, complained on admission of the absence of emission of faeces and gas since four days before with noticeable abdominal distension. In the physical examination he presented intestinal meteorism, a hard abdomen, painful on deep palpation in the median quadrants, especially in the epigastric and mesogastric ones. The abdominal X-RAY in the standing position confirms: an occlusive state with numerous liquid levels in the Ileum. Because of a worsening of the symptomatology and the appearance of generalized comprimission, two days later an exploratory laparotomy was performed. The intervention showed the presence of a Meckel's diverticulum with approximately 10 cm in length, with an ample neck, the distal Ileum for approximately 15 cm in dilation returned rapidly to a normal calibre, after a pastous endoluminal formation borne in the Meckel's diverticulum (Meckel resection presented actually a large niche at the fundus level with a eroded wall) and migrated in the distal Ileum where it could cause the obstruction. In the present case it is probably useful to perform a preoperative CT scan in order to get a precise etiology and perform an ascending Colonscopy, so avoiding a surgical procedure. According to the authors a CT scan is indicated in all cases of intestinal occlusion of unknown case, in order to have a more precise definition of the physiopathology of the occlusion.

[Surgery of large ventral hernias. Personal experience in 1990-1997]

BACKGROUND

The surgical treatment of large wall defects conventionally defined as an extension over 10 cm is discussed. The difficulty to contain the bowels that have lost law of domicile in the abdominal hollow, constitutes motive for notable increase of the endo-abdominal Pressure with serious consequences in the postoperative course and this leads to the use of prothesis meshes that allow the closing of the abdominal hollow with the Tension-Free technique.

METHODS

Personal experience embraces 45 patients, with large wall defects, divided into 21 patients with overumbilical location, 14 with umbilical location, 10 with periumbelical location; a simple suture has been used in 7 cases, the reconstruction of the wall according to Stoppa in 36 cases and the apposition of Goretex net internally and Marlex net externally in 2 cases.

RESULTS

There have been neither mortality, neither recidivists of illness, but only some complications: 9 cases of superficial infection, 1 case of intestinal occlusion and 2 of subcutaneous seroma.

CONCLUSIONS

According to their experience and wide literature review, the authors draw some conclusions: an accurate toilet and a careful evaluation of the respiratory functionality are fundamental; it's necessary to postpone surgical intervention in presence of local inflammation and, where this is improrogable it's opportune to avoid the use of prothesis meshes or refold on readsorbible prothesis; special care must be taken to the hemostasis and an aspirative drain for 24-48 hrs preserves from the risk of postoperative hematomas and following local infections. The submuscular mesh permits a Tension-Free suture and for this reason it would have nowdays a more extensive use. Finally it's pointed out the choice of a PTFEe mesh in contact with the intestinal skein.

The effect of valsartan on the angiotensin II pressor response in healthy normotensive male subjects

OBJECTIVE

Valsartan is an oral antagonist of angiotensin II that competes with angiotensin II for the AT1-receptor and is being developed as an antihypertensive agent. This study assessed the ability of 80 mg valsartan to inhibit the pressor effect of exogenous angiotensin II in healthy normotensive men, first after a single dose and then after multiple doses once daily for 7 days.

METHODS

This was a single-center, double-blind, placebo-controlled, randomized crossover study. Six healthy men underwent angiotensin II challenges to determine a suitable dose required to increase their systolic blood pressure by approximately 30 mm Hg. Each subject then received an 80 mg dose of valsartan or matching placebo. The inhibition of the angiotensin II pressor effect was determined by the systolic blood pressure response to repeated angiotensin II challenges at multiple time points.

RESULTS

Systolic blood pressure responses to angiotensin II challenges after single and multiple doses of valsartan were significantly lower than placebo, indicating that valsartan blocked the blood pressure response to angiotensin II. The maximum blocking effect was observed within 2 to 3 hours. Mean data suggested that differences in effect between valsartan and placebo were similar after both single and multiple doses and persisted up to 24 hours after administration. The angiotensin II blocking effect was maintained up to this time, despite low plasma valsartan levels and minimal accumulation after multiple doses.

CONCLUSION

Valsartan, 80 mg, is a potent angiotensin II antagonist with a rapid onset of action and persistent angiotensin II inhibition up to 24 hours. There is no attenuation of this effect after multiple doses.

The stomach in liver cirrhosis. Endoscopic, morphological, and clinical correlations

The stomachs of cirrhotic patients are frequently subject to a number of alterations, detectable by endoscopy, the presence of which indicates a disturbance in the mucosa. Several investigators believe that portal hypertension plays an etiopathogenetic role. Three groups of subjects were studied prospectively: 83 cirrhotic patients with portal hypertension, 53 cirrhotic patients without portal hypertension, and 135 control subjects. Snake skin, scarlatina rash, and petechia were the most frequent endoscopic findings in the cirrhotic patients with portal hypertension (P less than 0.001); these findings were also most frequently present in association with each other in this group. There was no correlation between the endoscopic findings, the clinical gravity of liver cirrhosis (Child-Pugh grade), and the gravity of esophageal varices (Beppu score). There were no characteristic inflammatory findings in the gastric mucosa. Hypergastrinemia was often observed in cirrhotic patients with and without angiodysplasias.

The duodenum in liver cirrhosis: endoscopic, morphological and clinical findings

Endoscopic studies were performed to determine whether changes occurred in the duodenum related to portal hypertension in patients with liver cirrhosis. The total of 271 patients studied were subdivided into three groups: 83 patients with liver cirrhosis and portal hypertension, 53 with liver cirrhosis but no portal hypertension, and 135 controls. In the duodenum of cirrhotic patients with portal hypertension several changes were observed on endoscopy that were also present in the other two groups. Atrophy and vascular malformations, however, were present only in the duodenum of cirrhotic patients with portal hypertension, although in only a few patients and with statistical significance only for vascular malformations (p less than 0.01, phi = 0.21). Eleven percent of the patients had more than one endoscopic finding, but the associations of findings were without statistical significance. No statistically significant correlation was observed between the clinical severity of cirrhosis or the severity of esophageal varices and the endoscopic findings. Finally, there was no statistically significant difference between the histological findings of duodenitis in the three groups of patients.

Pharmacokinetics of CGS 12970 and inhibition of thromboxane synthesis after oral administration in healthy adults

The pharmacokinetics and pharmacodynamics of biochemical effect of a selective thromboxane synthase inhibitor, CGS 12970, were studied in healthy male volunteers after a dosing scheme of either 200 mg once daily or 100 mg twice a day for 6 days. The peak plasma concentration appeared 1 to 2 hours after administration, followed by a biexponential decline with half life values of about 1 and 7 hours, respectively. The mean oral clearance was 16 L/hr. Biochemically, the capacity of the platelets to form thromboxane A2 ex vivo (serum) was inhibited greater than 90% at both doses. In contrast to the short plasma half-life, the suppression of ex vivo serum thromboxane production was maintained greater than 70% to 80% at 48 hours after dosing. Inhibition of the thromboxane production in vivo (urine) was also substantial, but incomplete at both doses (200 mg daily; thromboxane B2, 75%; 2,3-dinor-thromboxane B2, 83%; 11-dehydrothromboxane B2, 90%). The urinary excretion, however, returned to the predose level at the end of a 1-week follow-up period after the last dosing. In conclusion, CGS 12970 is an orally active, reversible inhibitor of thromboxane synthase with a prolonged duration of action in humans.

The influence of delta9-tetrahydrocannabinol on pilocarpine-induced parotid secretions of the rat

The effects of delta9-THC and its ethanol vehicle on pilocarpine-induced parotid gland secretions were investigated in rats. Single doses of delta9-THC (1, 2.5, 5 and 10 mg/kg) or 95% ethanol were administered i.v. prior to pilocarpine stimulation of saliva. Total flow, alpha-amylase and cation content of the induced saliva were determined at the end of the collection period; while heart rate and blood pressure were monitored throughout each experiment. The ethanol vehicle did not alter any of the parameters when compared to the pilocarpine controls. delta9-THC produced a bradycardia and hypotension which was not dose related in spontaneously breathing rats. Furthermore delta9-THC caused an increase in alpha-amylase concentration without a reduction in salivary flow. The results suggest that delta9-THC exerts a profound influence on the protein composition of parotid secretion which is independent of its cardiovascular effects and its ethanol vehicle.